Healthcare Provider Details

I. General information

NPI: 1013148840
Provider Name (Legal Business Name): LEAH COLLINS DOM, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2009
Last Update Date: 05/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1348 PACHECO ST SUITE 206
SANTA FE NM
87505-4222
US

IV. Provider business mailing address

1348 PACHECO ST SUITE 206
SANTA FE NM
87505-4222
US

V. Phone/Fax

Practice location:
  • Phone: 505-988-2449
  • Fax: 505-986-6005
Mailing address:
  • Phone: 505-988-2449
  • Fax: 505-986-6005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number999
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number3765
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: